Acute Epiploic Appendagitis: Clinical and Diagnostic Features of a Rare Cause of Acute Abdominal Pain

Abstract

Acute epiploic appendagitis is an uncommon, self-limiting cause of acute abdominal pain that is frequently misdiagnosed as acute appendicitis or diverticulitis. This condition results from ischemic infarction of epiploic appendages—small, fat-filled peritoneal pouches along the colon—due to torsion or spontaneous venous thrombosis. Despite accounting for approximately 1% of acute abdominal pain cases in adults, epiploic appendagitis remains underrecognized, leading to unnecessary hospitalizations, antibiotic use, and surgical interventions. The condition predominantly affects middle-aged males and is associated with increased visceral adiposity. Clinical presentation typically includes acute, localized, non-radiating abdominal pain without systemic symptoms such as fever, nausea, or vomiting. Laboratory investigations are usually normal or show minimal abnormalities. Computed tomography (CT) is the gold standard for diagnosis, demonstrating characteristic findings including an oval fat-density lesion adjacent to the colon with a hyperattenuating rim (ring sign) and central hyperdense dot. Ultrasonography can also identify the condition, showing a hyperechoic, non-compressible ovoid mass with a hypoechoic border and absent central blood flow on Doppler imaging. The primary differential diagnoses include acute diverticulitis, appendicitis, and omental infarction. Management is predominantly conservative, consisting of nonsteroidal anti-inflammatory drugs and observation, with symptoms typically resolving within 1-2 weeks. Surgical intervention is rarely required and reserved for complicated cases or diagnostic uncertainty. Recognition of the clinical and imaging features of epiploic appendagitis is essential to avoid unnecessary interventions and optimize patient outcomes. This review synthesizes current evidence on the epidemiology, pathophysiology, clinical presentation, diagnostic strategies, and management of acute epiploic appendagitis.